Thursday, 10 April 2008

Memento mori (2)

I wouldn't want you to think that general practice is all sickness, pain and disability. There's death, too. The other day a girl of about seven was brought to see me by her father. After we had dealt with the main problem he told me that she has been getting upset in the evenings. She cries and says that she is worried about things, such as the house being burgled or that she is going to die. A distant elderly relative is ill in hospital, but otherwise there has been nothing unsettling happening at home. She seems otherwise happy and is behaving normally. We had a little chat and she told me about some of her fears. I examined her heart and her lungs.

There was an interesting television programme the other night about memory. Research suggests that the reason we don't remember much that happens before we are five is because that is the age at which we develop a sense of self. Events prior to five are just random events that we observe but probably won't remember. Events after five are things that happen to us, they have a personal significance and so are much more likely to be remembered. From the age of about five until nine we gradually build up a picture of ourselves and our place in the world.

I discussed this with her and her father, saying that she is now working out her relationship with the world, and that includes coming to terms with the realisation that bad things may happen to her or her family and that they are all going to die one day. I think this is harder for children to cope with nowadays because news reporting on television is so emotional, with lengthy shots of grieving distressed people and presenters vying with each other to give the most harrowing report. The emphasis is frequently on how the events have happened to ordinary people in ordinary places. I reassured the girl that she looked very healthy and told her she is going to live for many years. I mentioned that one of my own children had similar fears at the same age, and I advised her father to encourage her to talk about her fears and give her lots of cuddles.

Her parents are separated and live apart, which I don't think is helping. It won't help her to see the world as a stable place and she may have some feelings of guilt about the separation. I didn't think it right to mention these thoughts.

I have also been doing some bereavement counselling. Last year I wrote about Simon, a man in his twenties supporting his much younger sister Janie who had a nasty form of cancer. Simon was more like a father than a brother to her, and the problem was always denial. Janie is not my patient so I have only had a distant view of events, but for a long time I tried to persuade Simon to face the truth a little more squarely, for his benefit as much as for Janie's. From his reports I could tell that Janie's consultant was trying to do the same thing, but he persisted in believing that there would always be a new course of treatment that could be tried. She has now died, and Simon is having difficulty coping. After all the busy-ness of attending hospital and arranging treatments he is left with nothing to do. It isn't fair that she has gone. He can't believe that he won't see her again. He needs to know that she is alright. And from a different perspective he is having to come to terms with our mortality, just like my seven-year-old patient.

I am doing my best to help him work out these thoughts and feelings, offering what I hope will be a little helpful explanation and suggestion. I know something of what he is feeling for I too have lost a child, but I have not mentioned this to him. I think it would in a sense be forcing my solution on him, and make light of his suffering - as though I were saying “that's happened to me too and I've got over it, so buck your ideas up and stop complaining”. Our grief is immense and personal, and only we can bear it.


Anonymous said...

Gosh doc, what a remarkable post. Pertinent and poignant for so many reasons. I'm glad you chose the profession in which you are find yourself - it is richer for it.

Anonymous said...

While the seven year old is developing that sense of negative things and how they somehow impact her, she's still young enough to not appreciate scale. So, worry about the possibility of death and separation and (perceived) abandonment are all felt, and all at pretty much the same level.

With the young man, it sounds as though, in addition to the normal grief you would expect, he has a real problem accepting that there are things - such as disease and death - which he can't control, no matter how much he wills it.

Very thought provoking post.

Anonymous said...

My condolences, AB

My life is richer thanks to you.

Thank you!

Dr Andrew Brown said...

Thanks, everyone.

Janeway - thank you for the insight about the need for the child to gain a sense of perspective. Some adults need to do the same, of course! And you are quite right that Simon's main problem is accepting that we can't control everything. Unfortunately society sends a very strong message to the contrary.

Anonymous said...

Dear Dr Brown
I think you are a wonderful writer. Have you thought of writing a book?
Best wishes
Clare Wilson

Dr Andrew Brown said...

That's very flattering, Clare.

I'm not sure that I have the ability to write a book, which is a much more complex undertaking than blogging. I certainly don't have the time at present. But if I amass enough material here I might try to turning it into a book when I retire.

Whether anyone would want to read it is another matter. :-)

Anonymous said...

But we enjoy reading it here - so obviously someone wants to read it!! Don't do yourself down!
The biggest problem I feel nowadays is actually not only the mass of hysterical claptrap on/in the media (although for the 7 year old confusing and scary) but the plain fact that death is run away from by everybody - often the GPs too who desperately try to get their dying patients into hospital rather than let them remain at home as it used to be. Death should be part of life - and for Simon's generation it wasn't. I have done my best not to run away so my children never found it fearful. I think I have succeeded - judging by their chosen careers/spare time occupations. Death shouldn't be scary - even if there are not very nice ways to die. It broke my heart to see the way part of our family denied the father's final illness at 58 from lung cancer - he'd never smoked. His beloved daughter only realied he was dying when it happened. I'd had to prepare the son a few weeks earlier because the parents hadn't told 25 and 27-year-olds their father was dying. If you don't know there is so much that may be missed doing - and then it it too late. She was out all day the day he died, only getting home minutes before it happened. She realised afterwards how close she had been to not being there and that was a terribly distressing feeling for her. It has left scars that need not have been.
I do hope you don't retire TOO soon - your patients will have much to miss. Wish you were in my practice!!

Anonymous said...

Agree with the compliments about the post, Andrew. Hit home with me as we have a (nearly) 4 yr old, who asks about things but does not have the kind of awareness you allude to - she just lives in the here and now.

Second the comment about the book. I think it would be a good read for all sorts of people, not least med students, junior doctors and GP trainees.

Would like to see Dr Grumble write a book too if he ever resurfaces.

Personally I think blogs-into-books work best if they are thinkered with as little as possible and selected posts simply put together as a kind of "diary". There is form anyway, see newspaper columnists publishing books of columns. One who stands out in my memory is the late John Diamond.

Dr Andrew Brown said...

Anonymous: thank you for your compliments and your story. I agree with every word.

Dr Aust: You're very kind. I will certainly think about the book idea.